- Case report
- Open Access
- Open Peer Review
Antegrade selective cerebral perfusion in patients with "bovine aortic arch": is it easier?
© Bizzarri et al; licensee BioMed Central Ltd. 2008
- Received: 15 July 2008
- Accepted: 04 November 2008
- Published: 04 November 2008
- Bicuspid Aortic Valve
- Axillary Artery
- Innominate Artery
- Left Common Carotid Artery
- Artery Cannulation
The term "bovine aortic arch" is widely used to describe a common anatomic variant of the human aortic arch branching, regarding the common origin of the brachiocephalic and left common carotid artery from the aorta. This anatomy pattern is not generally found in the cattles and the term "bovine aortic arch" is a common misnomer in the medical literature. Nevertheless we use this term all the time we deal with this kind of arch anatomy. True incidence is not really known and it's not clear if an incidental correlation exists between this arch anomaly and bicuspid aortic valve with ascending aorta aneurysms or if an anatomic predisposition identifies a sort of syndrome involving the left ventricular outflow tract.
We report the medical records of 3 consecutive patients, with this anomaly, undergone surgical treatment of bicuspid aortic valve pathology and ascending aorta aneurysm under profound hypothermia and selective cerebral perfusion (SCP) through the right axillary artery.
We describe the outcomes of 3 consecutive patients seen with these anomalies treated with the same surgical technique at Cardiac Surgery Unit of Polo Pontino between March and April 2008.
This 62-year old man presented with signs and symptoms of acute pulmonary congestion. Echo evaluation revealed a bicuspid aortic valve with 4+ regurgitation, 45% ejection fraction and increased diameters of left ventricle. 64 slices CT scan evaluation showed a 7.5 cm dilatation of ascending aorta involving the proximal portion of the arch and "bovine" configuration of the arch. Coronary angiography revealed a 80% stenosis of descending anterior artery.
This 69-year-old man presented with exertion dyspnea. Echo evaluation revealed a bicuspid aortic valve with 3–4+ regurgitation, 35% ejection fraction. 64 slices CT scan evaluation showed a 6.5 cm dilatation of ascending aorta involving the proximal portion of the arch and "bovine" configuration of the arch. Coronary angiography showed a normal coronary tree.
This 59-year-old man presented with thoracic pain and exertion dyspnea. Echo evaluation revealed, as the other patients, a bicuspid aortic valve with 4+ regurgitation and 40% ejection fraction. 64 slices CT scan evaluation showed a 8.0 cm dilatation of ascending aorta extending to the proximal portion of the arch and "bovine " configuration of the arch. Coronary angiography revealed a two vessel disease, 85% stenosis of descending anterior artery and 75% stenosis of the right coronary artery.
Operations were performed through a median sternotomy after isolation of the right axillary artery at the deltoideus-pectoralis groove. After systemic heparinization, a cardiopulmonary bypass (CPB) was instituted with an arterial cannula introduced into the right axillary artery and with a venous single two-stage cannula introduced into the right atrium. Myocardial protection was achieved with a cold cristalloid cardioplegia (Bretschneider solution) through the coronary sinus and through the coronary ostia. Cerebral monitoring was achieved by means of noninvasive measure of brain oxygenation regional saturation of oxygen (rSO2, INVOS Cerebral Oximeter System, Somanetics Corporation, Troy, Michigan, USA). The patients were cooled down to a nasopharyngeal temperature of 25°C. Arterial blood pH was managed according to the α-stat method.
After the arrest, antegrade selective cerebral protection (ASCP) was performed according to Kazui et al. protocol  by clamping the origin of the "bovine trunk". Cerebral perfusion was initiated at a flow rate of 10 ml/Kg.
An open distal anastomosis was first performed, then ASCP was stopped and the systemic circulation restored and the patient rewarmed. Ascending aorta and valve were replaced by means a valved tube with coronary reimplantation (modified Bentall procedure) and coronary artery grafting, at least, in patient 1 and 3. In all the patient the average of ASCP time was 20 ± 3.3 minutes.
Written informed consent was obtained from the patients for publication of this case report and the accompanying image. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Borger MA, Preston M, Ivanov J: Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?. J Thorac Cardiovasc Surg. 2004, 128: 677-83.View ArticlePubMedGoogle Scholar
- Kazui T, Inoue N, Yamada O, Komatsu S: Selective cerebral perfusion during operation for aneurysms of aortic arch. A reassessment. Ann Thorac Surg. 1992, 53: 109-14.View ArticlePubMedGoogle Scholar
- Pacini D, Leone A, Di Marco L, Marsilli D, Sobaih F, Turci S, Masieri V, Di Bartolomeo R: Antegrade selective cerebral perfusion in thoracic aorta surgery: safety of moderate hypotermia. Eur J Cardiothorac Surg. 2007, 31: 618-622. 10.1016/j.ejcts.2006.12.032.View ArticlePubMedGoogle Scholar
- Urbanski PP, Lenos A, Lindemann Y, Weigang E, Zacher M, Diegeler A: Carotid artery cannulation in aortic surgery. J Thorac Cardiovasc Surg. 2006, 132: 1398-1403. 10.1016/j.jtcvs.2006.07.024.View ArticlePubMedGoogle Scholar
- Kouchoulos NT, Masetti P, Rokkas CK, Murphy SF: Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg. 2002, 74: S1885-7. 10.1016/S0003-4975(02)04153-X.View ArticleGoogle Scholar
- Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS: Bovine aortic arch variant in humans: clarification of a common misnomer. AJNR Am J Neuroradiol. 2006, 27 (7): 1541-1542.PubMedGoogle Scholar
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